How to course for insulin users

DIAGNOSIS of TYPE ONE DIABETES

For most children or young people they will find out very quickly after diagnosis that they will need to be on injected insulin for life. Perhaps they will have had symptoms of weight loss, drinking a lot and passing urine a lot. Others will have become very ill with diabetic ketoacidosis and will have been hospitalised.

More and more often younger people are being diagnosed with metabolic syndrome and type 2 diabetes. This is usually related to being overweight, sedentary and genetic influences. Women with type 2, gestational or type one diabetes may find themselves being intensively treated with insulin during the planning or carriage of a pregnancy. Out with pregnancy most people with type 2 diabetes will remain on diet and oral medications to control their diabetes. After about six years around half of type 2 diabetics will have needed to add insulin to their medication regimes to maintain good control. Diabetics who use certain drugs to stimulate the pancreas to produce more endogenous insulin from their own pancreatic beta cells are more at risk of beta cell failure.

Type one diabetes results when the pancreas can no longer make enough insulin to prevent high blood sugars. For early onset patients it is an autoimmune disease that used to be a death sentence. Now that insulin is widely available for most people it is rarely as rapidly fatal. But until a real cure can be found and made available it can still feel like a life sentence.

Insulin is a drug that needs to be used very carefully. It can rapidly lower blood sugars and cause hypoglycaemia which can cause death if it is very severe and is untreated. Lower levels of hypoglycaemia may not be obvious to drivers or their passengers and yet can cause impaired reaction times and judgement which can lead to accidents. High blood sugars are less of a worry on the short term but on the long term damage accumulates that can severely affect the nerves, eyes, kidneys and heart.

Pancreatic beta cells start to die in tissue culture at sugar levels of 6.1 or higher. This is not a threshold effect and if blood sugar levels are brought below this level soon enough the cells can start to recover.

At the time of diagnosis and for up to decades afterwards type one diabetics still produce a small amount of insulin. The remaining beta cells are still subject to attack by autoimmune antibodies but can be nursed along for many years if high blood sugars can be avoided.

The more of your own pancreatic beta cells that are still active the easier it is to control your diabetes as the pancreas can still fine control sugar levels in a way that injections cannot. This is a major reason for all new diabetics to strive for normal blood sugars so they can prolong the “honeymoon” phase of diabetes.

Even the most rapidly effective injected insulins eg novorapid and humalog cannot replicate the immediately effective blood sugar lowering effect of the stored insulin from a normal pancreas beta cells. This means that blood sugars will be inappropriately high for at least some time after even small amounts of very fast releasing carbohydrates are eaten in eg bread or fruit. Over the long term these sugar spikes can add up to a lot of damage to body tissues.

We have already discussed what level of control you already have and what level of control may be optimal for certain groups of people in the Type Two Section. Please take a moment or two to review this.

This Type One section aims to give you more specific information on the use of insulin and other information to help you achieve the best health you can.

The insulin users section tends to lean heavily towards younger type ones. I will give some guidance about when older type twos can skip.Quick Quiz: 1. For insulin users it is safe to go straight onto a low carb diet as long as you have…
a Thrown out all your crisps, breakfast cereals and biscuits.
b Bought a good low carb book to help you.
c Bought in plenty of meat, vegetables and olive oil.
d Planned out a gradual reduction of carbohydrates and appropriate reduction in your insulin.

2. Type One diabetics…
a Make plenty of their own insulin from beta cells in the pancreas.
b Can be sure there will be a cure within the next five years.
c Rely on carefully measured and timed amounts of injected insulin to keep well.
d Can eat whatever they like, when they like.

3. You are an insulin user going into hospital for a planned operation. You need to do three of these….
a Speak to an anaesthetist well before your operation to let them know how you manage your blood sugars.
b Speak to the dietician about your meal choices from the Healthy Diabetic section of the menu.
c Bring in your insulins, testing kit and any special foods or drinks you may need.
d Arrange for a friend to provide, transport, supplies and to liaise with clinical staff.

4.Type ones can do three of these things…
a Get other autoimmune diseases.
b On first diagnosis go through a honeymoon period when pancreatic function improves for a period of time.
c Use inhaled insulin to control blood sugars.
d Die rapidly from severe hypoglycaemia.

5. Tests type ones should be having regularly include three of these…
a Amylase which is raised in pancreatitis.
b Thyroid function tests.
c Tissue transglutamase for coeliac disease.
d Albumin creatinine ratio which is a kidney test.Have you got it?
1. D is correct. You MUST plan and change your diet and insulin doses GRADUALLY. This means more frequent blood sugar testing till you are stable on your new regime.

2. C is correct. If only we could be certain of a widely available and affordable cure within the next five years then we possibly could eat what we want, when we want without paying too much for the consequences. Unfortunately for the foreseeable future most certainly DO have to live with the consequences so the tighter the control the better for most diabetics.

3. You need to do ACD. You don’t need to speak to the dietician. You decide yourself from the entire menu.

4. ABD are correct. Inhaled insulin was withdrawn for marketing reasons. There are other forms of insulin sprays in development. The most likely market is type twos who still have some pancreatic function.
5. Tests type ones should be having regularly include three of these…

For: Parents of type one children aged 9 and over and teenagers with type one diabetes

I will discuss the physical effects, the psychological effects and the effects on blood sugar control.

Puberty starts in girls around the age of 10 due to the secretion of growth and sex hormones. This is all carefully coordinated between the brain and sex glands. The growth in these hormones peaks at the age of 14 and then gradually subsides. Menstruation starts around the age of 12 or 13. For boys puberty starts around the age of 12, they generally overtake their mothers in height at the age of 14. The hormonal peak for boys is at 17 and then there is the gradual reduction. The bones of humans fuse at the age of 22 and from then on no more growth in height occurs.

The change in appetite around puberty is extremely pronounced. Instead of pleading with your children to eat their dinner, you have to plead with them not to eat yours as well. They will all snack. They will develop a taste for high carb/high fat foods as sold in Greggs in the UK and Krispey Kremes or Hortons in the USA. Some may get quite tubby and then sudden shoot up six inches over the summer. You will have a hard job keeping up with shoes and clothes that reach their wrists and ankles.

Inside their brains a lot of pruning is going on. Brain pathways that they don’t use get lost and ones that they do firm up. Moodiness can be expected due to the changes that go on. Teenagers tend to stay up later but need a lot more sleep and need to sleep in late when they can.

For 14 year old teenage girls who have diabetes the natural rebellion they feel against their mothers could hardly come at a worse time.

Socially teenagers are both trying to fit in with their peer group and define their sense of self by exploring their differences. They want to take decisions for themselves but often lack self organisational skills and perspective. They may make utterly daft decisions. They don’t want to be babied but they need you help to almost the same extent, just in a different way.

Parents are a great resource for teenagers. In a study of type two diabetic teenagers the hbaic of those with good parental support was 7% compared to 11% for poor parental support. In a study of type one UK 16 year old teenagers girls had a hbaic 2% higher than the 16 year old teenage boys. There is a menstruation effect here with girls too, but a strong difference was that 16 year old girls tended to deal with their diabetes management themselves and didn’t want their mum to interfere. The boys however were happy to have their mums help them and it didn’t affect their self esteem at all.

Some diabetic clinics exclude parents from the consultation once their child turns 14. This is rather silly of the doctors because the parents are the ones who have to pick up the pieces when things go wrong.

The average hba1c for Scottish teenagers is around 9.5-10%. But this can be greatly reduced by optimal diet and precision insulin management.

The first thing you will notice about puberty is that blood sugars will increase. The next thing you will notice is that you will need more insulin to cover the same meals as you used to and that you need more insulin to correct high blood sugars than you used to. These are the easy bits.

The hard bit is dealing with the dawn phenomenon. This is the rise in blood sugars you get in the morning due to all the hormones that are secreted during the night. Why is this hard? Because whereas the other two are predictable and consistent, the effect of the dawn phenomenon is unpredictable and inconsistent.

In all cases you are going to end up giving more insulin. For the meal insulins you simply gradually increase the amount of insulin you give for a given amount of carbohydrate. For instance you could be giving a pre-pubertal child one unit of insulin to cover 14g of carb and find that at the peak of insulin resistance this drops to 3g of carb. The complex thing is that your carbohydrate/insulin ratios vary according to the time of day. You usually have to give a lot more insulin at breakfast compared to lunch and dinner for instance. In a short while I will show you how to work this out. If you have a smart meter such as the Accucheck Expert System, it will work it out for you.

For correction doses you are doing a similar thing. A general rule of thumb is that one unit of novorapid will drop you 2.5 points UK. This is for a non insulin resistant 10 year old kid. The smaller the size of the child the less insulin is needed to get the same drop in blood sugar. As you get more insulin resistant such as: you get bigger, the nearer you are to “peak” age, your blood sugars are higher, you are ill, it is early in the morning, it is just before your period the amount will generally increase. It can be one unit of insulin dropping one unit of blood sugar at the peak of insulin resistance. You have to find out what correction factors work for you. There is no short cut for self experimentation.

The problem with blood sugar management with even the easy stuff like carb/insulin ratios for meals and correction doses is that you are aiming to shoot at a target that is moving all the time. Almost as soon as you’ve got it nailed they are off growing again. You can expect this to go on till their peak age 14 for girls and 17 for boys.

This is how you work out carb/insulin ratios if you don’t have a fancy meter that does this for you. Once a week take your child’s insulin kit and meters from their bag. Empty out all the old used test strips and lancets and needles and put new ones in the kit. Write down all the blood sugar readings in columns related to pre-breakfast, pre-lunch, pre-dinner and pre-bed. Add up the average of the week under all these columns. If the average is between 4 and 6 (UK) or 72 and 108 (US) do nothing different about the ratios. If they are higher or lower than this I think about why this is and I consider altering the carb/insulin ratio. You must handle the pre-breakfast blood sugars differently as I will explain later. On your way up to the peak age you will be gradually giving more insulin and as you go away back down from the peak you will gradually give less insulin.

You also look at the number of hypos, for us 3.5 (UK) and 63 (US) or under and try to think why this is happening. It means that the meal / insulin matching is out in some way. It could also be due to too high basal insulin. It could be the result of unusual physical activity. It could also be due to eating less than expected. You do need to consider if you need to cut the insulin ratio, or revise your carb counting more accurately. The first sign that your child’s insulin resistance is lessening as they come down from their peak insulin resistance could be night time hypos or low blood sugars after breakfast as the dawn phenomenon becomes less pronounced.

The big problem with the dawn phenomenon is its unpredictability. From my experience it was on most of the time but off about one day in ten. We never knew which day. Blood sugars could be 5 UK or 90 US at bedtime, 5 UK or 90 US at 3am and 15 UK or 270 US at 8am. We could not up the night basal insulin because this would have given a severe night hypo one night in ten. It is terribly frustrating dealing with this but my best advice is that you must sit it out.

When you are doing your blood sugar logs, you only bother about morning blood sugars when they are too low. If the 7am is too low or your 3am is too low you have to cut your night basal insulin. If the 3am is too high, and this is not due to what your kid has eaten, then you can raise the night basal insulin. If the morning blood sugar is too high, this is the dawn phenomenon and you have to sit it out. One blood sugar that is too high, can often be disregarded, but patterns in blood sugar must be examined and dealt with. Even a single low blood sugar may need a change in insulin doses and we will discuss the detective work involved with this in the hypoglycaemia section.

Another factor for high morning blood sugars that you need to consider is a re-bound high if there is a hypo in the night. Dr Bernstein doesn’t think this phenomenon exists but after speaking to a lot of diabetics I think it does. A clue is if you wake up sweaty, or wake up after a nightmare. In this case you may need to decrease your night time basal insulin.

Blood sugar sensitivity varies according to the seasons. In general you get more insulin sensitive in the summer. You are exposed to more natural vitamin D in the summer and this could be one reason. Hba1cs usually go up half a percent in the winter. Minor variations in your basal insulin and carb insulin ratios are going on all the time.

So, this is what goes on as you go up the insulin resistance peak. What goes on when you go down? Just as the dawn phenomenon is the worst aspect of the upswing, there is a big problem with the downswing. The problem to look out for is unpredictable and sometimes severe hypos. Although the climb to the peak is generally slow and progressive the downswing can be quite sharp. The vigilance that is required here is to keep a close eye on basals and low blood sugars, remembering to check at 3am occasionally. If you detect a trend towards low blood sugars reduce the appropriate insulin before it becomes critical. Even then you can still be caught out. The insulin dose your adult child will eventually need could be between 1/3 and 2/3 of what they are on at their peak. The amount will depend on their natural level of insulin resistance, body weight and dietary preferences.

You need to be very vigilant in doing hypo detective work and as your child growns it is important that you both look at the weekly blood sugar pattern and adjust as necessary. This has been greatly helped by the use of the Accuchek Aviva Expert System. This is available from hospital clinics and some GP practices. To be eligible for this, it is preferable that you have already done the preparatory work we describe on this course. This includes carbohydrate counting for all meals and knowledge of your meal/insulin ratios.

Quiz: Which of the options is NOT correct:

At the onset of puberty:

Children become more insulin sensitive.

Their appetite increases greatly.

Blood sugars rise in the mornings.

They can become more moody.

Parents of teenage diabetics:

Can remind their children to check blood sugars.

Can prepare nutritious low glycaemic meals.

Can check 3am blood sugars from time to time.

Have no place in discussion with endocrinolgists about their child’s management.

On the way up to age 14 for girls and 17 for boys:

Insulin resistance increases gradually.

The dawn phenomenon is unpredictable.

The amount of insulin needed for breakfast is less.

The amount of insulin they need for a given amount of carb increases.

On the way down from age 14 for girls and 17 for boys:

Insulin resistance can decrease steeply.

Girls stop having so much blood sugar fluctuation at their periods.

They may need less basal insulin.

They may have more hypos.

Answers: 1. 1 is not correct. Their insulin resistance increases. 2. 4 is correct. Parents need to be involved in their childs health care whether health care professionals like it or not. 3. 3 is correct. Insulin requirements rise and breakfast is when insulin resistance is most pronounced. 4. 2 is correct. Girls continue to have considerable fluctuations in their blood sugars around the time of their periods.

youthhealthtalk.org/diabetes Is a UK based site where 38 type ones aged 15-25 have given video interviews about a wide range of issues that affect them. It includes how to deal with parents, travel abroad, eating disorders and much, much more. Sadly, Ann McPherson, the GP who set up the site died of cancer in 2012.

Helping diabetic teenagers optimise their blood sugars is a challenge for everyone in the family. How have your family managed?

Emergency cards personalised to you

Hypoglycaemia

I have diabetes and I take insulin or medicine which can lower my blood sugar.
Low blood sugar levels can cause death and brain damage. Please help me.

If I cannot be woken up or walk or talk easily please take me to a hospital with an accident and emergency department or call an emergency ambulance right away.
I will need to have a glucose drip to raise my blood sugar.

If I am confused please give me a glucose drink. I may have glucose gel, tablets or a sugar drink in my pockets or bag.

I have already taken a glucagon injection.

I have not taken any glucagon.

Thank you.

Name
DOB
Passport Number
Contact Phone No

Vomiting and Diabetes

I have insulin dependent diabetes.

I need to see a doctor at an accident and emergency department right away.

I am very ill and need an intravenous saline drip.

I think I am developing diabetic ketoacidosis.

I have been vomiting repeatedly. I cannot stop.

Please phone an emergency ambulance right away.

My blood sugar is now………………………………………….

I am showing ketones in my urine.

I am not showing ketones in my urine.

I think the cause of the high blood sugars is:

I have an infection.

I did not take enough insulin.

I got dehydrated.

Thank you for helping me.

Name
DOB
Passport Number
Contact Phone Number

Food Choices

I have diabetes. To keep my blood sugars as normal as possible I need to eat more of some foods and less of others.

I particularly find that eating certain grains and starches can make me feel very ill.

It is very important that I am able to choose food from the entire menu and choose the portion size of the foods that I need.

Thank you for your understanding.

Self Monitoring of Blood Sugar

I have diabetes. I do my best to keep my blood sugars as normal as I can when I am at home.

Having very good blood sugar control is particularly important in a hospital and when getting over illnesses or operations when infection can so easily get a hold in someone with diabetes.

Because I have developed such a fine personal awareness of exactly how best to manage my blood sugars it is essential that I continue to do this for myself while I am here.

I would therefore ask you to respect the need for my blood sugar monitoring kit to be beside me at all times.

I will also need to have:

My insulin delivery kit.

My “hypo” food and drink kit.

My drinking water.

Thank you with your help for this most important part in getting me well again.
I really appreciate it.

Foreign Travel

It is a good idea to construct personalised emergency information before you ever need admitted to hospital. I made these cards out in several languages, laminated them and take them on holiday. I also have constructed similar cards with frequently chosen foods to make ordering in restaurants easier.

If you plan to travel to an area where you are NOT fluent in the language you can use google translate or babelfish to translate any text that you type in. Many languages are available from both sites.

Reference Info:

Acknowledgements to the bablefish and google sites. What a great idea!